Pathways to Obesity Prevention: Report of a National Institutes of Health Workshop1

Using a Cultural Framework to Assess Motivation for Physical Activity Among Older Hispanic Women: Application of the PEN-3 Model

Culturally relevant strategies for intervention design and implementation, emphasizing strengths and resources, are essential to address cardiovascular health disparities among older Hispanic women. The purpose of this article is to present the process and results of focus group discussions conducted to understand the meaning of cultural, social, and contextual strengths to promote motivation for physical activity and cardiovascular health in this population. The PEN-3 model guided analysis of focus group data. Fifteen older Hispanic women (mean = 61, SD = 6) participated in 3 focus groups. Three interrelated domains were evaluated: (a) cultural identity, (b) relationships and expectations, and

Food Environments and Obesity: Household Diet Expenditure Versus Food Deserts

OBJECTIVES

To examine the associations between obesity and multiple aspects of the food environments, at home and in the neighborhood.

METHODS

Our study included 38,650 individuals nested in 18,381 households located in 2104 US counties. Our novel home food environment measure, USDAScore, evaluated the adherence of a household's monthly expenditure shares of 24 aggregated food categories to the recommended values based on US Department of Agriculture food plans. The US Census Bureau's County Business Patterns (2008), the detailed food purchase information in the IRi Consumer Panel scanner data (2008-2012), and its associated MedProfiler data set (2012) constituted the main sources for neighborhood-, household-, and individual-level data, respectively.

RESULTS

After we controlled for a number of confounders at the individual, household, and neighborhood levels, USDAScore was negatively linked with obesity status, and a census tract-level indicator of food desert status was positively associated with obesity status.

CONCLUSIONS

Neighborhood food environment factors, such as food desert status, were associated with obesity status even after we controlled for home food environment factors.

Longitudinal Weight Loss Patterns and their Behavioral and Demographic Associations

BACKGROUND

Identification of weight change patterns may allow tailored interventions to improve long-term weight loss.

PURPOSE

To identify patterns of weight change over 18 months, and assess participant characteristics and intervention adherence factors associated with weight change patterns in a sample of 359 overweight/obese adults.

METHODS

Weight loss (0-6 months) was achieved with reduced energy intake and increased physical activity (PA). Maintenance (7-18 months) provided adequate energy to maintain weight and continued PA.

RESULTS

Latent profile analysis identified three weight change profiles. During weight loss/maintenance, participants in profiles 2 and 3 (18-month weight loss ∼14 %) attended more behavioral sessions and performed more PA compared with profile 1 (18-month weight loss <1 %). Self-efficacy for both weight management and exercise barriers were higher in profiles 2 and 3 compared with profile 1 following weight loss and during maintenance.

CONCLUSION

Weight change patterns can be identified and are associated with both participant characteristics and intervention adherence.

A group randomized controlled trial integrating obesity prevention and control for postpartum adolescents in a home visiting program

BACKGROUND

Adolescence represents a critical period for the development of overweight that tracks into adulthood. This risk is significantly heightened for adolescents that become pregnant, many of whom experience postpartum weight retention. The aim of this study was to evaluate Balance Adolescent Lifestyle Activities and Nutrition Choices for Energy (BALANCE), a multicomponent obesity prevention intervention targeting postpartum adolescents participating in a national home visiting child development-parent education program.

METHODS

A group randomized, nested cohort design was used with 1325 adolescents, 694 intervention and 490 control, (mean age = 17.8 years, 52 % underrepresented minorities) located across 30 states. Participatory methods were used to integrate lifestyle behavior change strategies within standard parent education practice. Content targeted replacement of high-risk obesogenic patterns (e.g. sweetened drink and high fat snack consumption, sedentary activity) with positive behaviors (e.g. water intake, fruit and vegetables, increased walking). Parent educators delivered BALANCE through home visits, school based classroom-group meetings, and website activities. Control adolescents received standard child development information. Phase I included baseline to posttest (12 months); Phase II included baseline to follow-up (24 months).

RESULTS

When compared to the control group, BALANCE adolescents who were ≥12 weeks postpartum were 89 % more likely (p = 0.02) to maintain a normal BMI or improve an overweight/obese BMI by 12 months; this change was not sustained at 24 months. When compared to the control group, BALANCE adolescents significantly improved fruit and vegetable intake (p = .03). In stratified analyses, water intake improved among younger BALANCE teens (p = .001) and overweight/obese BALANCE teens (p = .05) when compared to control counterparts. There were no significant differences between groups in sweetened drink and snack consumption or walking.

CONCLUSION

Prevention of postpartum weight retention yields immediate health benefits for the adolescent mother and may prevent the early development or progression of maternal obesity, which contributes to the intergenerational transmission of obesity to her offspring. Implementing BALANCE through a national home visiting organization may hold promise for promoting positive lifestyle behaviors associated with interruption of the progression of maternal obesity.

TRIAL REGISTRATION

Clinical Trials Registry NCT01617486 .

We can do that! Collaborative assessment of school environments to promote healthy adolescent nutrition and physical activity behaviors

Evidence for effectiveness of school-based studies for prevention of adolescent obesity is equivocal. Tailoring interventions to specific settings is considered necessary for effectiveness and sustainability. The PRECEDE framework provides a formative research approach for comprehensive understanding of school environments and identification of key issues/areas to focus resources and energies. No reported studies have tested applicability of the PRECEDE framework in schools in relation to obesity. Adolescents (n = 362), parents (n = 349) and teachers (n = 146) from six secondary schools participated in two quantitative studies and two qualitative studies. Data collected from these studies permitted confirmation of adolescent overweight/obesity a health issue for schools; the need for secondary schools to focus health promotion efforts on healthy nutrition, with inclusion of parents/homes and appreciation for gender differences in developing interventions. Community buy-in and commitment to school-based obesity prevention programs may be dependent on initially addressing what may be perceived as minor issues, and developing policies to guide practices within schools in relation to supply and access to healthy foods, use of sporting equipment and participation in physical activities. The PRECEDE framework allows systematic assessment of school environments and provided opportunity to identify realistic and relevant interventions for promoting healthy adolescent physical activity and nutrition behaviors.

Development of an innovative process evaluation approach for the Families Improving Together (FIT) for weight loss trial in African American adolescents

This study demonstrates how a multi-theoretical, multilevel process evaluation was used to assess implementation of the Families Improving Together (FIT) for weight loss intervention. FIT is a randomized controlled trial evaluating a culturally tailored, motivational plus family-based program on weight loss in African American adolescents and their parents. Social Cognitive, Self Determination, Family Systems theories and cultural tailoring principles guided the conceptualization of essential elements across individual/family, facilitator, and group levels. Data collection included an observational rating tool, attendance records, and a validated psychosocial measure.

RESULTS

Attendance records (0=absent, 1=present, criteria=≥70%) indicated that 71.5% of families attended each session. The survey (1=false, 6=true, criteria=≥4.5) indicated that participants perceived a positive group climate (M=5.16, SD=0.69). A trained evaluator reported that facilitator dose delivered (0=no, 1=yes, criteria=≥75%) was high (99.6%), and fidelity (1=none to 4=all, criteria=≥3) was adequate at facilitator (M=3.63, SD=0.41) and group levels (M=3.35, SD=0.49). Five cultural topics were raised by participants related to eating (n=3) and physical activity (n=2) behaviors and were integrated as part of the final curriculum.

DISCUSSION

Results identify areas for program improvement related to delivery of multi-theoretical and cultural tailoring elements. Findings may inform future strategies for implementing effective weight loss programs for ethnic minority families.

An overview of the Families Improving Together (FIT) for weight loss randomized controlled trial in African American families

BACKGROUND

The Families Improving Together (FIT) randomized controlled trial tests the efficacy of integrating cultural tailoring, positive parenting, and motivational strategies into a comprehensive curriculum for weight loss in African American adolescents. The overall goal of the FIT trial is to test the effects of an integrated intervention curriculum and the added effects of a tailored web-based intervention on reducing z-BMI in overweight African American adolescents.

DESIGN AND SETTING

The FIT trial is a randomized group cohort design the will involve 520 African American families with an overweight adolescent between the ages of 11-16 years. The trial tests the efficacy of an 8-week face-to-face group randomized program comparing M + FWL (Motivational Plus Family Weight Loss) to a comprehensive health education program (CHE) and re-randomizes participants to either an 8-week on-line tailored intervention or control on-line program resulting in a 2 (M + FWL vs. CHE group) × 2 (on-line intervention vs. control on-line program) factorial design to test the effects of the intervention on reducing z-BMI at post-treatment and at 6-month follow-up.

INTERVENTION

The interventions for this trial are based on a theoretical framework that is novel and integrates elements from cultural tailoring, Family Systems Theory, Self-Determination Theory and Social Cognitive Theory. The intervention targets positive parenting skills (parenting style, monitoring, communication); cultural values; teaching parents to increase youth motivation by encouraging youth to have input and choice (autonomy-support); and provides a framework for building skills and self-efficacy through developing weight loss action plans that target goal setting, monitoring, and positive feedback.

'Fit Moms/Mamás Activas' internet-based weight control program with group support to reduce postpartum weight retention in low-income women: study protocol for a randomized controlled trial

BACKGROUND

High postpartum weight retention is a strong independent risk factor for lifetime obesity, cardiovascular disease, and type 2 diabetes in women. Interventions to promote postpartum weight loss have met with some success but have been limited by high attrition. Internet-based treatment has the potential to overcome this barrier and reduce postpartum weight retention, but no study has evaluated the effects of an internet-based program to prevent high postpartum weight retention in women.

METHODS/DESIGN

Fit Moms/Mamás Activas targets recruitment of 12 Women, Infants and Children (WIC) Supplemental Nutrition Program clinics with a total of 408 adult (>18 years), postpartum (<1 year) women with 14.5 kg or more weight retention or a body mass index of 25.0 kg/m(2) or higher. Clinics are matched on size and randomly assigned within county to either a 12-month standard WIC intervention or to a 12-month WIC enhanced plus internet-based weight loss intervention. The intervention includes: monthly face-to-face group sessions; access to a website with weekly lessons, a web diary, instructional videos, and computer-tailored feedback; four weekly text messages; and brief reinforcement from WIC counselors. Participants are assessed at baseline, six months, and 12 months. The primary outcome is weight loss over six and 12 months; secondary outcomes include diet and physical activity behaviors, and psychosocial measures.

DISCUSSION

Fit Moms/Mamás Activas is the first study to empirically examine the effects of an internet-based treatment program, coupled with monthly group contact at the WIC program, designed to prevent sustained postpartum weight retention in low-income women at high risk for weight gain, obesity, and related comorbidities.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (identifier: NCT01408147 ) on 29 July 2011.

A pilot study of the effects of a tailored web-based intervention on promoting fruit and vegetable intake in African American families

BACKGROUND

The current study examined the effects of a Web-based tailored parenting intervention on increasing fruit and vegetable intake in African American families.

METHODS

Forty-seven African American parents (mean age, 41.32 ± 7.30; 93.6% female) with an adolescent (mean age, 13.32 ± 1.46; 59.6% female) participated in a Web-based autonomy-support parenting tailored intervention session to increase both parent and youth fruit and vegetable (F&V) intake. The session lasted 45-60 minutes and included three phases: a feedback phase; a Web-based information phase, and a goal-setting and action plan phase. Self-reported measures of parenting skills [based on autonomy (choice), support, and communication] and F&V intake (assessed as average daily intake) were assessed at baseline and at a 1-week follow-up session.

RESULTS

There was a significant increase in parents' self-reports of daily fruit intake from pretest to the 1-week follow-up. Parent and adolescent combined F&V intake also significantly increased from pretest to 1-week follow-up. Overall, parents reported that the program was easy to navigate and that they enjoyed participating in the Web-based online program.

CONCLUSIONS

Current findings provide preliminary support for an autonomy-support parent tailored Web-based program for improving dietary intake in African American families.

Are network-based interventions a useful antiobesity strategy? An application of simulation models for causal inference in epidemiology

Recent research suggests that social networks may present an avenue for intervention against obesity. By using a simulation model in which artificial individuals were nested in a social network, we assessed whether interventions targeting highly networked individuals could help reduce population obesity. We compared the effects of targeting antiobesity interventions at the most connected individuals in a network with those targeting individuals at random. We tested 2 interventions, the first "preventing" obesity among 10% of the population at simulation outset and the second "treating" obesity among 10% of the obese population yearly, each in 2 separate simulations. One simulation featured a literature-based parameter for the network spread of obesity, and the other featured an artificially high parameter. Interventions that targeted highly networked individuals did not outperform at-random interventions in simulations featuring the literature-based parameter. However, in simulations featuring the artificially high parameter, the targeted prevention intervention outperformed the at-random intervention, whereas the treatment intervention implemented at random outperformed the targeted treatment intervention. Results were qualitatively similar across network topologies and intervention scales. Although descriptive studies suggest that social networks influence the spread of obesity, policies targeting well-connected individuals in social networks may not improve obesity reduction. We highlight and discuss the potential applications of counterfactual simulations in epidemiology.

Why culture matters in health interventions: lessons from HIV/AIDS stigma and NCDs

Theories about health behavior are commonly used in public health and often frame problems as ascribed or related to individuals' actions or inaction. This framing suggests that poor health occurs because individuals are unable or unwilling to heed preventive messages or recommended treatment actions. The recent United Nations call for strategies to reduce the global disease burden of noncommunicable diseases like diabetes requires a reassessment of individual-based approaches to behavior change. We argue that public health and health behavior intervention should focus more on culture than behavior to achieve meaningful and sustainable change resulting in positive health outcomes. To change negative health behaviors, one must first identify and promote positive health behaviors within the cultural logic of its contexts. To illustrate these points, we discuss stigma associated with obesity and human immunodeficiency virus and acquired immune deficiency syndrome. We conclude that focusing on positive behaviors and sustaining cultural and personal transformations requires a culturally grounded approach to public health interventions, such as that provided by the PEN-3 model.

Family-focused physical activity, diet and obesity interventions in African-American girls: a systematic review

Obesity interventions that involve family members may be effective with racial/ethnic minority youth. This review assessed the nature and effectiveness of family involvement in obesity interventions among African-American girls aged 5-18 years, a population group with high rates of obesity. Twenty-six databases were searched between January 2011 and March 2012, yielding 27 obesity pilot or full-length prevention or treatment studies with some degree of family involvement and data specific to African-American girls. Interventions varied in type and level of family involvement, cultural adaptation, delivery format and behaviour change intervention strategies; most targeted parent-child dyads. Some similarities in approach based on family involvement were identified. The use of theoretical perspectives specific to African-American family dynamics was absent. Across all studies, effects on weight-related behaviours were generally promising but often non-significant. Similar conclusions were drawn for weight-related outcomes among the full-length randomized controlled trials. Many strategies appeared promising on face value, but available data did not permit inferences about whether or how best to involve family members in obesity prevention and treatment interventions with African-American girls. Study designs that directly compare different types and levels of family involvement and incorporate relevant theoretical elements may be an important next step.

Effect of an environmental school-based obesity prevention program on changes in body fat and body weight: a randomized trial

This study tested the efficacy of two school-based programs for prevention of body weight/fat gain in comparison to a control group, in all participants and in overweight children. The Louisiana (LA) Health study utilized a longitudinal, cluster randomized three-arm controlled design, with 28 months of follow-up. Children (N = 2,060; mean age = 10.5 years, SD = 1.2) from rural communities in grades 4-6 participated in the study. Seventeen school clusters (mean = 123 children/cluster) were randomly assigned to one of three prevention arms: (i) primary prevention (PP), an environmental modification (EM) program, (ii) primary + secondary prevention (PP+SP), the environmental program with an added classroom and internet education component, or (iii) control (C). Primary outcomes were changes in percent body fat and BMI z scores. Secondary outcomes were changes in behaviors related to energy balance. Comparisons of PP, PP+SP, and C on changes in body fat and BMI z scores found no differences. PP and PP+SP study arms were combined to create an EM arm. Relative to C, EM decreased body fat for boys (-1.7 ± 0.38% vs. -0.14 ± 0.69%) and attenuated fat gain for girls (2.9 ± 0.22% vs. 3.93 ± 0.37%), but standardized effect sizes were relatively small (<0.30). In conclusion, this school-based EM programs had modest beneficial effects on changes in percent body fat. Addition of a classroom/internet program to the environmental program did not enhance weight/fat gain prevention, but did impact physical activity and social support in overweight children.

Research capacity building: a US-South African partnership

Research capacity building engenders assets that allow communities (and, in this case, student fellows) to respond adequately to health issues and problems that are contextual, cultural and historical in nature. In this paper, we present a US-South African partnership that led to research training for 30 postgraduate students at two South African universities. We begin by exploring the nature of research capacity building in a partnership research project designed to promote HIV and AIDS-related stigma reduction. We examine methodological issues and their relevance to training of postgraduate students in South Africa. We conclude with recommendations for a successful model of partnership for building capacity of health researchers in Africa with the goal of developing research that informs policies and helps to bridge the health inequity gap globally.

Stigma, Culture, and HIV and AIDS in the Western Cape, South Africa: An Application of the PEN-3 Cultural Model for Community-Based Research

HIV- and AIDS-related stigma has been reported to be a major factor contributing to the spread of HIV. In this study, the authors explore the meaning of stigma and its impact on HIV and AIDS in South African families and health care centers. They conducted focus group and key informant interviews among African and Colored populations in Khayelitsha, Gugulethu, and Mitchell's Plain in the Western Cape province. The audio-recorded interviews were transcribed and coded using NVivo. Using the PEN-3 cultural model, the authors analyzed results showing that participants' shared experiences ranged from positive/nonstigmatizing, to existential/unique to the contexts, to negative/stigmatizing. Families and health care centers were found to have both positive nonstigmatizing values and negative stigmatizing characteristics in addressing HIV/AIDS-related stigma. The authors conclude that a culture-centered analysis, relative to identity, is central to understanding the nature and contexts of HIV/AIDS-related stigma in South Africa.

What is a healthy body weight? Perspectives of overweight youth

PURPOSE

A qualitative assessment was completed of overweight/obese youths' perceptions of the meaning of "healthy body weight," barriers and facilitators to healthy body weight attainment, and what would effectively enhance and support their healthy body weight behaviours.

METHODS

This qualitative study targeted a sample of overweight and obese youth, aged 14 to 16 years. An experienced interviewer conducted 11 in-depth interviews. Interviews were audio-recorded and transcribed verbatim. Three qualitative researchers conducted independent and simultaneous inductive content analysis to facilitate confirmability. Data trustworthiness was supported via member checking, peer debriefing, and reflexive journalling.

RESULTS

Most participants characterized healthy body weight as a combination of healthy eating and regular physical activity. Some included a psychological dimension in the definition. Perceived facilitators of a healthy body weight included family support, access to nutritious food at home, physical activity encouragement, and a physical activity environment at school. Perceived barriers included lack of family support, a poor nutrition environment, an unsupportive school environment, time, self-esteem, and bullying. Participants identified preferences for an intervention that would include opportunities for unstructured coeducational recreational activities, coeducational nutrition education sessions, and a gender-specific discussion forum.

CONCLUSIONS

Participants provided a wealth of information to form the foundation of future youth-focused efficacious healthy body weight interventions.

Disparities in physical activity and sedentary behaviors among US children and adolescents: prevalence, correlates, and intervention implications

Regular physical activity is important for health benefits among youth, but disparities exist. This paper describes disparities in physical activity participation and sedentary behaviors among youth in the United States, provides intervention implications, and offers recommendations for future research focused on reducing disparities related to levels of physical activity. Secondary analysis of national accelerometer data showed that achievement of recommended levels of physical activity ranged across subgroups from 2% to 61%. Mean hours per day spent in sedentary behavior ranged from 5.5 to 8.5. The largest disparities were by gender and age. An improved understanding of correlates may inform the design of interventions to increase physical activity in targeted subgroups. Additional theoretically based research is needed to elucidate which factors contributing to physical activity disparities are amenable to change via intervention. To eliminate health disparities, changes in policies that have an impact on physical activity may be necessary to promote physical activity among high-risk youth.

Gender-ethnic disparity in BMI and waist circumference distribution shifts in US adults

While obesity has been increasing in the United States, little is known about the variation in recent BMI and waist circumference (WC) distribution shifts across socio-demographic groups. We assessed shifts in BMI and WC distributions and compared between-group differences over the past decade, and projected future BMI and WC distributions and prevalence of obesity and central obesity using National Health and Nutrition Examination Survey (NHANES) 1988-1994 and 1999-2004 data. BMI/WC distributional shifts overall and in percentiles were compared across groups. Average yearly shift was calculated and used for projecting future distributions and prevalence. Both BMI and WC increased more in their uppermost percentile distribution, though BMI shift declined toward the uppermost percentiles among women. Heavier Americans gained more adiposity over the past decade. Ethnic (non-Hispanic (NH) white vs. black) disparities in mean BMI and WC became wider. Over the survey period, mean BMI increased by 1.3 units vs. 1.8 units among men and women, whereas WC, by 4.2 cm vs. 4.8 cm. Young adults had the largest increase. Shift in women's WC was stable between the 25th and 75th percentiles, but gained pace at higher WC, while women's BMI and men's BMI and WC shifts increased linearly. NH black women had the largest shifts and would have central obesity and obesity prevalence of 90.8 and 70.7% by 2020. Shifts in BMI and WC distribution varied across age-, gender-, and ethnic groups. Future rise in the obesity and central obesity prevalence rates are expected, but would vary by demographic groups.

Weight gain prevention: identifying theory-based targets for health behavior change in young adults

Young adults attending college are more vulnerable to weight gain than the general population. We sought to identify health behavior change targets related to weight management in college students. Based on the Social Cognitive Theory model for health behavior change, we investigated the health-related lifestyle behaviors and physiological characteristics of this population. Forty-three college students (18.3+/-0.1 years) completed a series of quantitative assessments (eg, body weight and composition, cardiorespiratory fitness, and diet and activity habits) and structured qualitative assessments (ie, structured interview or focus group). Participants were predominantly normal weight (mean body mass index 22.2+/-0.4) and fit (maximal oxygen consumption 50.5+/-1.5 mL/kg/minute). However, healthful eating and physical activity were not considered high priorities, despite having ample free time, high exercise self-efficacy, positive outcome expectations for exercise, and a desire to exercise more. Participants reported that regularly engaging in exercise was difficult. This may have been due to poor planning/time management, satisfaction with body image, lack of accountability, and feelings of laziness. Dietary patterns generally met recommendations but were low in fruits, vegetables, and whole grains. Social support for exercise and healthful dietary habits were important factors associated with health behaviors. Students reported a decline in exercise and dietary habits relative to high school, which may have contributed to college weight gain. Our results suggest that this population may not have adequate self-regulatory skills, such as planning and self-monitoring, to maintain healthful behaviors in the college environment. Food and nutrition professionals working with young adults attending college may use these findings to guide the behavioral therapy component of their weight management medical nutrition therapy goals and outcomes.

Will all Americans become overweight or obese? estimating the progression and cost of the US obesity epidemic

We projected future prevalence and BMI distribution based on national survey data (National Health and Nutrition Examination Study) collected between 1970s and 2004. Future obesity-related health-care costs for adults were estimated using projected prevalence, Census population projections, and published national estimates of per capita excess health-care costs of obesity/overweight. The objective was to illustrate potential burden of obesity prevalence and health-care costs of obesity and overweight in the United States that would occur if current trends continue. Overweight and obesity prevalence have increased steadily among all US population groups, but with notable differences between groups in annual increase rates. The increase (percentage points) in obesity and overweight in adults was faster than in children (0.77 vs. 0.46-0.49), and in women than in men (0.91 vs. 0.65). If these trends continue, by 2030, 86.3% adults will be overweight or obese; and 51.1%, obese. Black women (96.9%) and Mexican-American men (91.1%) would be the most affected. By 2048, all American adults would become overweight or obese, while black women will reach that state by 2034. In children, the prevalence of overweight (BMI >/= 95th percentile, 30%) will nearly double by 2030. Total health-care costs attributable to obesity/overweight would double every decade to 860.7-956.9 billion US dollars by 2030, accounting for 16-18% of total US health-care costs. We continue to move away from the Healthy People 2010 objectives. Timely, dramatic, and effective development and implementation of corrective programs/policies are needed to avoid the otherwise inevitable health and societal consequences implied by our projections .

A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults

In the past, interventions aimed at reducing obesity have mainly targeted at weight loss treatment in obese adults, with limited long-term effects. With the increasing number of people being obese and being at risk for obesity, there has been a shift in focus towards prevention of obesity. We conducted a systematic review of the peer-reviewed literature on the efficacy of obesity prevention interventions in adults in order to identify effective interventions and intervention elements. Pubmed, OVID, and Web of Science databases were searched from January 1996 to June 2006. Interventions aimed at primary prevention of weight gain among adults achieved by focusing on dietary intake, physical activity or the combination of both were included. The outcome measure had to be difference in change in body mass index or body weight between the intervention and the control groups. Nine studies were included, five long-term studies (at least 1 year) and four short-term (3 months to 1 year). Seven studies evaluated an intervention that focused on a combination of diet and physical activity to prevent weight gain, one on diet only and one on physical activity only. One dietary intervention (long-term), and three combined dietary and physical activity interventions (one long-term and two short-term) produced significantly positive results at end of follow-up. The two long-term, effective interventions consisted of intensive and long-term intervention implementation, including groups sessions designed to promote behavioural changes. The current evidence of efficacy of obesity prevention interventions is based on a very small number of studies. Some studies showed a positive impact on body mass index or weight status, but there was too much heterogeneity in terms of study design, theoretical underpinning and target population to draw firm conclusions about which intervention approaches are more effective than others. More research is urgently needed to extend the body of evidence.

Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science)

Obesity is a major influence on the development and course of cardiovascular diseases and affects physical and social functioning and quality of life. The importance of effective interventions to reduce obesity and related health risks has increased in recent decades because the number of adults and children who are obese has reached epidemic proportions. To prevent the development of overweight and obesity throughout the life course, population-based strategies that improve social and physical environmental contexts for healthful eating and physical activity are essential. Population-based approaches to obesity prevention are complementary to clinical preventive strategies and also to treatment programs for those who are already obese. This American Heart Association scientific statement aims: 1) to raise awareness of the importance of undertaking population-based initiatives specifically geared to the prevention of excess weight gain in adults and children; 2) to describe considerations for undertaking obesity prevention overall and in key risk subgroups; 3) to differentiate environmental and policy approaches to obesity prevention from those used in clinical prevention and obesity treatment; 4) to identify potential targets of environmental and policy change using an ecological model that includes multiple layers of influences on eating and physical activity across multiple societal sectors; and 5) to highlight the spectrum of potentially relevant interventions and the nature of evidence needed to inform population-based approaches. The evidence-based experience for population-wide approaches to obesity prevention is highlighted.

Childhood obesity: looking into the future

A major concern related to childhood obesity is that obese children tend to become obese adults, with all the risks/ comorbidities associated (ie, diabetes, cardiovascular diseases among many others). The challenges of childhood obesity are not limited to one country but confront most nations around the world. Efforts to manage and to prevent childhood obesity involve education, research, and intervention. Research could drive new directions in prevention and could develop public policy that might help manage the problem. Additionally, research is needed to test these issues. Looking into the future, 6 relevant levels may be involved in the prevention and treatment of pediatric obesity, and each of these needs investigation: family, schools, health care, government, industry, and media. Together, these 6 levels could promote childhood obesity as a high research priority and put it as the first point in the international public agenda.

Maintenance of weight loss in overweight middle-aged women through the Internet

OBJECTIVE

The purpose of this study was to compare weight regain in a group of perimenopausal women (48.0+/-4.4 years old), randomized to a 12-month weight maintenance Internet intervention or to self-directed weight maintenance after a 4-month weight loss treatment.

METHODS AND PROCEDURES

After a 4-month behavioral weight loss program, 135 women were randomized to either Internet or self-directed groups. The Internet group (n=66) used a website to gain information and complete logs concerning their weight, diet, and exercise progress over a 12-month follow-up. The 69 self-directed women had no contact with study staff. All women were measured for weight and body composition, and diet intake, and were interviewed using the 7-day physical activity questionnaires at baseline, 4 months, and 16 months.

RESULTS

At the end of the 12-month follow-up, the Internet and self-directed groups had regained on average 0.4+/-5.0 kg and 0.6+/-4.0 kg, respectively (P=0.5). In within-group analyses, Internet diet-log entries were correlated with follow-up weight change (r=-0.29; P<0.05) and moderately with change in exercise energy expenditure (EEE; r=0.44; P<0.01). Follow-up weight change was not correlated with change in dietary intake.

DISCUSSION

While significant weight loss was maintained over follow-up by both groups of women, Internet use did not surpass self-direction in helping to sustain weight loss. Among Internet users, Internet use was related to weight change and EEE.

Memphis Girls health Enrichment Multi-site Studies (GEMS)

Obesity prevalence is increasing in the U.S., especially among children and minority populations. This report describes the design and baseline data of the ongoing Girls health Enrichment Multi-site Studies (GEMS) trial (Memphis site), which is testing the efficacy of a 2-year family-based intervention to reduce excessive increase in body mass index (BMI). This randomized, controlled trial conducted at community centers in Memphis, Tennessee requires major measurements at baseline and at 12 and 24 months post-randomization. The participants are healthy African-American girls and one parent/caregiver of each girl. Participating girls are of ages 8-10 years, with BMI>or=25th percentile of the CDC 2000 growth charts or with one overweight or obese parent/caregiver (BMI>or=25 kg/m(2)). The active intervention is designed to prevent excessive weight gain by promoting healthy eating habits and increasing physical activity. An alternative intervention (comparison group) promotes general self-esteem and social efficacy. The main outcome measure is the difference between the two treatment groups in the change in BMI at 2 years. Three hundred and three girls have been randomly assigned to receive the test intervention (n=153) or the alternative intervention (n=150). The two groups do not differ in baseline characteristics. At the time of enrollment, the mean age was 9 years, the mean BMI was 22 kg/m(2) (mean BMI percentile=77 th), and 41% were overweight (BMI>/=95th percentile using CDC 2000 growth charts). Participants' intake of fruits and vegetables (1.3 serving/day) and fats (36% kcal), and their participation in moderate-to-vigorous physical activity (20 min/day), did not meet national recommendations. The GEMS obesity prevention intervention targets improved diet and increased physical activity to reduce excessive weight gain in healthy African-American girls of ages 8-10.

Childhood obesity: are we missing the big picture?

Childhood obesity is increasing worldwide, raising alarm about future trends of cardiovascular disease, diabetes and cancer. This article discusses what may underlie our failure to respond effectively to the obesity epidemic, and presents a wider perspective for future research and public health agendas. So far targeting individual-level determinants and clinical aspects of childhood obesity has produced limited success. There is growing interest in understanding the wider determinants of obesity such as the built environment (e.g. walkability), social interactions, food marketing and prices, but much needs to be learned. Particularly, we need to identify distal modifiable factors with multiple potential that would make them attractive for people and policymakers alike. For example, walking-biking-friendly cities can reduce obesity as well as energy consumption, air pollution and traffic delays. Such agenda needs to be driven by strong evidence from research involving multi-level influences on behaviour, as well as the study of wider politico-economic trends affecting people's choices. This article highlights available evidence and arguments for research and policy needed to curb the obesity epidemic. The upstream approach underlying these arguments aims to make healthy choices not only the most rational, but also the most feasible and affordable.

Managing Excessive Weight Gain During Pregnancy and the Postpartum Period

Childbearing is a period in the life cycle during which some women may gain weight, become overweight, or become obese. Despite guidelines issued in 1990 for gestational weight gain, many women exceed them. Women who are overweight before pregnancy are most vulnerable to excessive gestational weight gain. Prenatal interventions to prevent excessive gain have had mixed results. During the postpartum period, 14% to 20% of women may retain weight from pregnancy, which elevates risk of later health problems. Although postpartum weight loss interventions have been shown to have efficacy, these have been tested primarily with White women. Continued efforts are needed in practice and research to develop effective approaches for managing weight during pregnancy and postpartum, especially for low-income and ethnic minority women.

Placing the burden on the individual: overweight and obesity in African American and mainstream women's magazines

One third of all U.S. adult women, and more than 75% of African American women, are overweight or obese. This study examined overweight and obesity editorial content (N=406) in three mainstream and three African American women's magazines between 1984 and 2004. Content analysis was used to determine which strategies were suggested regarding diet, overweight, and obesity, which components of social cognitive theory were offered (behavior, person, or environment), and whether or not there were differences in the genres. The results suggest that although a wide range of strategies were being offered, the vast majority were behavioral changes with an individual solution focus. Although African American and mainstream magazines suggested many of the same strategies, nearly half more frequently appeared in one or the other genre. Mainstream magazines were twice as likely to offer the limiting or eliminating of fast food or junk food, eating more protein, eating lower-fat foods, and eating smaller portions. African American magazines were much more likely to cover fad diets and to suggest readers rely on God or faith in their diet plans. The average number of strategies offered per article was significantly higher in mainstream than in African American magazines.

Two-year internet-based randomized controlled trial for weight loss in African-American girls

OBJECTIVE

A randomized controlled trial tested the efficacy of an internet-based lifestyle behavior modification program for African-American girls over a 2-year period of intervention.

RESEARCH METHODS AND PROCEDURES

Fifty-seven overweight (mean BMI percentile, 98.3) African-American girls (mean age, 13.2 years) were randomly assigned to an interactive behavioral internet program or an internet health education program, the control condition. Overweight parents were also participants in the study. Forty adolescent-parent dyads (70%) completed the 2-year trial. Outcome data including BMI, body weight, body composition, and weight loss behaviors were collected at baseline and at 6-month intervals. A computer server tracked use of the web sites.

RESULTS

An intention-to-treat statistical approach was used, with the last observation carried forward. In comparison with the control condition, adolescents in the behavioral program lost more mean body fat (BF) (-1.12 +/- 0.47% vs. 0.43 +/- 0.47% BF, p < 0.05), and parents in the behavioral program lost significantly more mean body weight (-2.43 +/- 0.66 vs. -0.35 +/- 0.64 kg, p < 0.05) during the first 6 months. This weight loss was regained over the next 18 months. After 2 years, differences in fat for adolescents (-0.08 +/- 0.71% vs. 0.84 +/- 0.72% BF) and weight for parents (-1.1 +/- 0.91 vs. -0.60 +/- 0.89 kg) did not differ between the behavioral and control programs.

DISCUSSION

An internet-based weight management program for African-American adolescent girls and their parents resulted in weight loss during the first 6 months but did not yield long-term loss due to reduced use of the web site over time.

Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment

The prevalence of overweight among children and adolescents has dramatically increased. There may be vulnerable periods for weight gain during childhood and adolescence that also offer opportunities for prevention of overweight. Overweight in children and adolescents can result in a variety of adverse health outcomes, including type 2 diabetes, obstructive sleep apnea, hypertension, dyslipidemia, and the metabolic syndrome. The best approach to this problem is prevention of abnormal weight gain. Several strategies for prevention are presented. In addition, treatment approaches are presented, including behavioral, pharmacological, and surgical treatment. Childhood and adolescent overweight is one of the most important current public health concerns.